BACKGROUND Spontaneous portosystemic shunts (SPSS) frequently develop in liver cirrhosis. Recent data suggested that presence of a single large SPSS is associated with complications, especially overt hepatic encephalopathy (oHE). However, presence of >1 SPSS is common. This study evaluates the impact of total cross-sectional SPSS area (TSA) on outcome of patients with liver cirrhosis. METHODS In this retrospective international multicentric study, computed tomography (CT) scans of 908 cirrhotic patients with SPSS were evaluated for TSA. Clinical and laboratory data were recorded. Each detected SPSS radius was measured and TSA calculated. 1-year survival was primary and acute decompensation (oHE, variceal bleeding, ascites) secondary endpoint. RESULTS 301 patients (169 male) were included in the training cohort. 30% of all patients presented >1 SPSS. TSA cut-off of 83 mm2 was determined to classify patients with small or large TSA (S-/L-TSA). L-TSA patients presented higher MELD (11 vs. 14) and more commonly history of oHE (12% vs. 21%, p<0.05). During follow up L-TSA patients developed more oHE episodes (33% vs. 47%, p<0.05) and showed lower 1-year survival than S-TSA (84% vs. 69%, p<0.001). Multivariate analysis identified L-TSA (HR 1.66, 1.02-2.70, p<0.05) as independent predictor of mortality. An independent multicentric validation cohort of 607 patients confirmed L-TSA patients with lower 1-year survival (77% vs. 64%, p<0.001) and more oHE development (35% vs. 49%, p<0.001) than S-TSA. CONCLUSION This study suggests that TSA >83mm2 increases the risk for oHE and mortality in liver cirrhosis. Our results may have impact on clinical use of TSA/SPSS for risk stratification and clinical decision-making considering management of SPSS.

中文翻译：

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自发性门体分流总面积可独立预测肝硬化患者的肝性脑病和死亡率

背景自发性门体分流术(SPSS) 经常发生在肝硬化中。最近的数据表明，单个大型 SPSS 的存在与并发症有关，尤其是明显的肝性脑病 (oHE)。但是，存在>1 SPSS 是常见的。本研究评估了总横截面 SPSS 面积 (TSA) 对肝硬化患者预后的影响。方法 在这项回顾性国际多中心研究中，对 908 名使用 SPSS 的肝硬化患者的计算机断层扫描 (CT) 扫描进行了 TSA 评估。记录临床和实验室数据。测量每个检测到的 SPSS 半径并计算 TSA。1 年生存率是主要和急性失代偿（oHE、静脉曲张出血、腹水）次要终点。结果 301 名患者（169 名男性）被纳入训练队列。30% 的患者出现 > 1 数据统计。确定了 83 mm2 的 TSA 截止值来对具有小 TSA 或大 TSA (S-/L-TSA) 的患者进行分类。L-TSA 患者呈现较高的 MELD（11 对 14）和更常见的 oHE 病史（12% 对 21%，p<0.05）。在随访期间，L-TSA 患者发生更多的 oHE（33% 对 47%，p<0.05）并且显示出比 S-TSA 更低的 1 年生存率（84% 对 69%，p<0.001）。多变量分析确定 L-TSA（HR 1.66，1.02-2.70，p<0.05）是死亡率的独立预测因子。一个由 607 名患者组成的独立多中心验证队列证实 L-TSA 患者的 1 年生存率较低（77% 对 64%，p<0.001）和更多的 oHE 发展（35% 对 49%，p<0.001）比 S-运输安全管理局。结论 本研究表明，TSA >83mm2 会增加肝硬化患者的 oHE 风险和死亡率。